The transformation of non-ICU into ICU facilities may compromise patient safety in terms of infections

Dear Editor,

It is with great concern to watch the worldwide transformation of non-intensive care unit (ICU) into ICU facilities in a way to cope with the increased demand for ICU beds for COVID-19 patients.

Operating in an ICU requires well-trained professionals and well-established infection prevention and control (IPC), as well as antimicrobial stewardship practices by the healthcare professionals involved in patient care.

Invasive devices that are often used in ICUs, such as endotracheal tubes, central vascular catheters, and urinary catheters, can potentially lead to device-associated healthcare-associated infections if IPC practices are not properly used. There is evidence that among COVID-19 patients, the most common type of infection seems to be device-associated. Ventilator-associated pneumonia (VAP) comes first, followed by bacteremia with sepsis and urinary tract infections (UTIs) (Nag and Kaur, 2021). In a retrospective study in China, more than 30% of COVID-19 patients acquired VAP, and 24% bacteremia (He et al., 2020). DA-HAIs are known to severely increase the mortality rate (Koch et al., 2015) especially if involving a resistant, multi-resistant, or pan-resistant strain of bacteria. Despite the limited data, it is believed that at least half of the patients who died from COVID-19 had coinfection with super bacteria (Nag and Kaur, 2021). Our local unpublished data indicate a high colonization rate or/and high DA-HAIs prevalence among these patients.

Antimicrobial stewardship principles are another important aspect of patient care that seems to be neglected during the pandemic (Huttner et al., 2020). Bacterial infections require antimicrobials. However, distinguishing the bacterial from a viral infection is often difficult. A large proportion of COVID-19 patients, that are in the need of ICU hospitalization, present fever, cough, and radiological infiltrates, which lead to the decision of prescribing antibiotics despite the viral disease origin. It is well evidenced that the misuse of antibiotics increases resistance (Llor and Bjerrum, 2014) leading to superinfections.

When ICU beds are increasing, non-trained staff recruitment is unavoidable. Additionally, the extreme environmental pressure forces staff to exhaustion. Non-well-trained staff in combination with exhaustion, increased patient disease severity, the extended length of ICU, older patient ages, and misuse of antibiotics can potentially be a lethal combination.

ICUs are far more than equipment and staff. Training the staff, establishing IPC, and antimicrobial stewardship practices take more time than that it required to transform a non-ICU facility into an ICU. Therefore, rushed decisions may severely compromise patient safety in terms of DA-HAIs and superinfections.

We have to keep in mind that whatever we sow today we will unquestionably reap in the future.